easter seals iowa · 2018-01-31 · 1 easter seals iowa resident camp 2018 checklist *****please...
TRANSCRIPT
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EasterSealsIowa
ResidentCamp2018Checklist*****Please allow up to 2 weeks of processing of applica on once ALL paperwork from checklist below has been received to the Program and Support Specialist. Please send all items together, in one shipment, in order to begin the process of the applica on. Sending par al applica ons does not hold or reserve a spot for your camper. ***** Adult: Ages 18 & Up, Youth: 4‐17 Check in—Sunday a ernoon 2:00‐4:00 pm. Check out—Friday between 2:00‐3:00 pm. This program can be paid for with Waiver Services or Private Pay. Waiver is code T2036, $1.24/unit, 484 a week. Private Pay Cost: $600 per week.
As you complete the applica on, please check off the items from this list: ___ 2018 Applica on (Signature on last page) ___ All Release Forms (Waiver of Liability, Photo Consent Form, No ce of Privacy Prac ces) ___ Health History ___ Physical Form (valid for 2 years) + immuniza on records (Signature required—we do not accept electronic signature) ___ Current Individual Care Plan (ICP)/Consumer Comprehensive Service Plan (CCSP) and Release of Informa on (Please contact your case manager) ___ Financial Informa on Form ___ Resident Camp Registra on Form ___ $50 non‐refundable deposit or authorized Waiver Funding (Waiver clients only—please contact your Case Manager) ***Please do NOT send deposit separately.*** You may send them to our Program and Support Specialist, by the following methods: Email: [email protected] Mail or Drop Off: Easter Seals Iowa A n: Camp and Respite 401 NE 66th Ave Des Moines, IA 50313 Once we have registered you for camp, you will receive a le er via mail confirming the week(s) you are registered for. Please contact the Program and Support Specialist 515‐309‐2375 or [email protected] if you
have any ques ons. Thank you for choosing Easter Seals Iowa!
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EasterSealsIowaCampSunnyside‐ResidentApplication2018‐
Are you privately paying? [ ] YES [ ] NO If so, please a ach $50 deposit. The other $550 is due before camper can a end camp.
Client Informa on (Please Print Legibly)
Last Name: First Name: Middle Name:
Address:
City/State: County: Zip Code:
Phone: Cell Phone:
Social Security Number: Medicaid ID:
Email: Birthdate: / /
Office use only:
Gender: Female Male Preferred Pronoun: He She Other If Other:___________
Preferred Language:
Marital Status: Single Married/Cohabita ng Separated Divorced Widowed
Ethnicity: Asian American African American Caucasian Hispanic Na ve American
Mul ple Ethnici es Choose Not to Say Other: _____________________
Military Status : Ac ve Member of Military/Vet Family Na onal Guard/Reserve N/A Veteran
Waiver Designa on: Brain Injury Brain Injury + DD Children’s Mental Health
$100% County Case Management DD Case Management Elderly
Health and Disability Health and Disability + DD HIV/AIDS Waiver
Intellectual Disability Physical Disability Physical Disability + DD
SIS Score: SIS Type: Full OYA Client: Income / Employment
Monthly Income:
(If Applicable)
Source: Community Employment Other SSDI SSI
Notes:
Employments [ ] Is Current?
Employer: Posi on:
Employer Contact Info
Address:
City/State: County: Zip Code:
Supervisor: Phones: Contact Hours:
Wage: Start Date: End Date:
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Guardian Informa on
First Name: Last Name: Rela onships:
Address:
City/State: County: Zip Code:
Home Phone: Cell Phone: Work Phone:
Email: Interpreter: Yes No
Primary Language: Preferred Method of Contact:
Group Home (If Applicable)
Name of Home: Address:
City/State: County: Zip Code:
Phone: Contact Person:
Managed Care Informa on
Which Managed Care Organiza on (MCO) are you using?
United Healthcare Group Amerigroup HIPP/IME
Managed Care Policy Number:
Case Manager: Phone: Fax:
Agency: Email:
Address: City/State: Zip Code:
Healthcare Provider
Regular Physician:
Address: City/State: Zip/Code:
Day me Phone: Fax Number:
Preferred Hospital (In the event of an emergency)
Broadlawns Mercy Medical Unity Point—Lutheran Unity Point—Methodist
Unity Point Blank Children’s Other_____________________________
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Personal Hygiene (Brushing teeth, shower etc.)
Level of Assistance Needed: Independent Some Assistance Total Assistance [ ] Verbal Prompt
Detail of level of Assistance:
Toile ng
Do you wear A ends/Briefs/Diapers? Yes No If yes, when? All Day Night Only
Bathroom Assistance:
Independent Some Assistance Total Assistance Assistance with cleaning a er BM
Uses the following:
[ ] Colostomy Appliance [ ] Digital S mula on [ ] In‐Dwelling Catheter
[ ] Suprapubic Catheter [ ] Ileto Appliances [ ] Urinary Catheter
[ ] Intermi ent Catheteriza on [ ] Urinal [ ] Other
Do you need assistance with the above? Yes No
Detail Level of Assistance:
Monitor BM?
Yes
No
Dressing
Level of Assistance Needed:
Independent Some Assistance Total Assistance [ ] Verbal Prompts
Detail Level of Assistance:
Communica on
Communica on Device Yes No Braille Yes No
Interpreter Yes No Type:__________________ Large Font Yes No
Visual Impairment Yes No Verbal Yes No
Non Verbal Yes No ASL Yes No
Other Communica on Needs:
Dietary Informa on (Please mark all that apply)
Are you on a special diet? [ ] YES [ ] NO
G‐Tube If so, are you NPO? Yes No
Mechanical So
Pureed
Fluid Restric on required per Physician
Other _____________________________
Are you Diabe c? Yes No
[ ] Medica on Controlled
[ ] Diet Controlled
[ ] Carb Count
[ ] Insulin Controlled
Ea ng: Eats Independently Total Assistance
[ ] Monitor Por ons
[ ] Help Cu ng Up Food
Notes:
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Ambula on and Care
Assistance Needed with Manual Wheelchair:
[ ] No Assistance [ ] Assist on Rough Ground [ ] Assist for Distances [ ] Total Assist [ ] N/A
Assistance with Transferring: Current Weight_________
[ ] No Assistance [ ] Stand and Pivot Transfer [ ] 2 Person Li (must be 100 lbs or less)
Other Ambula on Needs: [ ] Some Support on Certain Surfaces [ ] Support for long distances [ ] Support due to vision
Overnight Supports / Nigh me Rou ne
Level of Assistance Needed: Independent Some Assistance Total Assistance
Do you use any of the following: CPAP BiPAP Notes:
Do you sleep through the night consistently? Yes No If no, explain:_______________
The following works best if having difficulty falling asleep:
Elopement (Select All that Apply)
[ ] Stays with the Group [ ] Wanders Away [ ] Ac vely Leaves Group [ ] Hides [ ] Declines to Par cipate
Please Explain:
Tips to Redirect:
Seizures Do you have a seizure disorder? Yes [ ] No [ ] (if yes, please fill out the rest of this sec on) VNS: Yes No
What type of Seizures? Date of Last Seizure:
Frequency: Seizure Time/Length:
Known Triggers:
Behavior / Aura Prior to Seizure:
Type of Behavior During Seizure:
Recovery Time / Behavior A er Seizure:
Medical Interven on Plan: Rescue Med: Yes No
Do you use a safety helmet? Yes [ ] No [ ]
Assis ve Technology (Select all that apply ‐ underlined items are supplied by camp)
AFO/KAFO Aug/Alt Communica on Device Bed Rails Eye Glasses Hearing Aid TTY Shower Chair
Other Bathing Aid Gait Belt Grab Bars Hospital Bed Hoyer Li /Sling Crutches Cane
Walker Manual Wheel Chair Electric Wheelchair Ac vi es of Daily Living Devices Plate Guard
Modified Utensils Tray Slip Mat Specialized Cup Specialized Plate Other______________
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Medical Diagnosis
Primary: (please circle)
Mental Disorders Cerebral Palsy Scoliosis
Au sm Epilepsy Spina Bifida
Alcoholism/Drug Abuse Heart Disease Cle Palate
Other Psychological Disorders Asthma Down’s Syndrome
ADD/ADHD COPD Speech, Language & Voice Dysfunc on
Developmental Delays Diseases of the skin & ssue Spinal Cord Injury
Intellectual Disability Arthri s Head Injury
Secondary:
Other:
Verbal and Physical Aggression (towards self, others or property)
Not Aggressive May Strike or Swear Occasionally Regularly Strikes or Swears
Type: [ ] Physical [ ] Verbal [ ] Self‐Injurious Behaviors
Please Explain:
Staff Supports:
Client Coping Strategies:
Known Triggers:
Does the Camper
need an Epi Pen?
[ ] Yes [ ] No If yes, please explain:
Food Allergies:
Reac ons:
Other Notes:
Other Non‐Food
Allergies:
Reac ons:
Other Notes:
Allergies
***Please send a list of all medica ons, dosages and instruc ons and a ach to applica on.***
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By signing here, you give our healthcare staff the permission to provide rou ne healthcare, dispense medica ons, and seek emergency treatments.
Applica on Completed By: Date:
(Print)
Rela onship:
Signature of Legal Guardian:
(Must have guardian signature.. If camper is their own guardian camper must sign.)
Over‐S mula on
Causes: Large Groups Situa ons Noises Smells Other:___________________
Explain:
Support Recommenda ons:
History of Sexual Behavior
No Sexual behavior observed Unsolicited sexual comments Unsolicited sexual touching Masturba on
History of Sexual Abuse
YES NO
Support Recommenda ons:
Transi ons
Transi ons Well 5 Minute Warning Visual of Transi on Struggles with Transi ons
Support Recommenda ons:
Does the camper need assistance in the event of a fire, tornado, flood, or bomb threat? Yes No
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‐WAIVEROFLIABILITY‐*Signature Required*
Client Name: Program Name:
With the understanding that Easter Seals Iowa (herea er known as ESI) will make reasonable efforts to prevent accidents, injuries, or other mishaps, I acknowledge the following:
The undersigned, individually or as a parent or natural guardian, in par al recogni on of services rendered claims, demands, or ac ons, causes of ac on or suits of whatsoever kind or nature for damages sustained by the normal client or accruing to the undersigned in consequence of any
accident or occurrence resul ng from the use of durable medical equipment and/or par cipa on in any ac vity or program of ESI and regardless of whether the named client is not on the premises of said ESI, and is engaged in any venture or solely on his or her own behalf.
I give permission for the applicant to a end ESI sponsored programs and to ride in vehicles operated or leased by ESI.
I agree to not send this applicant to an ESI program if he or she has been exposed to contagious disease within three weeks of the star ng date of the program and to no fy Easter Seals Iowa Camping, Recrea on, and Respite services immediately if this situa on arises.
The‐applicant has permission to engage in all prescribed ac vi es except those noted by an examining physician or physician assistant and me. In the case of an emergency or ill health, I herby give permission to the physician selected by ESI to order x‐rays, rou ne test, and treatments. In the event I cannot be reached in an emergency, I herby give my permission to the physician selected by ESI to hospitalize, secure proper treatment for, to order injec ons and/or anesthesia and/or surgery for the named par cipant.
I understand that the par cipant is responsible for his/her own medical coverage and associated cost.
This release may be revoked in wri ng except to the extent ac on has been taken in reliance upon the release.
Iunderstandandagreetotheabovesection.
Signature of legally responsible person (parent, guardian, or applicant if own guardian):
Print Name: Date:
Sign Name: Rela onship:
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‐PhotoConsentForm
*Select1boxandSignatureRequired*
Client Name: Program Name:
I hereby consent that any narra ves, depic ons, pictures, film, photographs, audio‐visual or sound recordings or tes monials of me made by Easter Seals Iowa may be used by Easter Seals Iowa, and those ac ng with its permission, for the purpose of illustra on, broadcast, or tes monial in connec on with any work of Easter Seals Iowa and that these materials may be released to the general public. I assign to Easter Seals Iowa all of my rights to these materials. All photographs and other media which include your image are the sole property of Easter Seals Iowa. Such photos may be used at various mes unless you revoke this photo consent in wri ng. Any revoca on is valid from the date it is received by Easter Seals Iowa and will not apply to photos that have been used prior to the revoca on in any publica on or other media.
I understand that these materials may be published on Easter Seals Iowa's network of Web sites and this may disclose my personal and protected health informa on. To ensure the privacy of any person under age 18, Easter Seals Iowa will use only the first name and the loca on of the Easter Seals Iowa organiza on where a minor receives services. Easter Seals Iowa does not need to submit these materials to me for further approval. I understand that these materials may be modified and that Easter Seals Iowa may decide not to use them.
I acknowledge that the rights described above are granted to Easter Seals Iowa on an unlimited basis without any compensa on or payment being made for any current or future use. I understand that this authoriza on is voluntary and that Easter Seals Iowa will not condi on any treatment or funding to me on the comple on of this authoriza on. I also understand that I may revoke my consent to allow Easter Seals Iowa to release my protected health informa on if the informa on has not already been disclosed. To revoke my consent, I must no fy Easter Seals Iowa in wri ng by sending my revoca on to Easter Seals Iowa Intake/Marke ng Coordinator. I understand and agree that once Easter Seals Iowa, and those ac ng with its permission, disclose my protected health informa on as contemplated by this release, this informa on is subject to re‐disclosure and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996.
[ ] Yes ‐ please take and/or use my picture.
[ ] No ‐ please do not take and/or use my picture.
Ifullyunderstandthecontentsofthisreleaseandauthorization.
Camper Signature Date
Guardian Signature Date
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ACKNOWLEDGEMENTOFRECEIPTOFTHEEASTERSEALSIOWAINCORPORATED
NOTICEOFPRIVACYPRACTICES*Signature Required*
I, , acknowledge that I have received a copy of The Easter Seals Iowa Incorporated's No ce of Privacy Prac ces which summarizes the ways my iden fiable health informa on may be used and disclosed by Easter Seals Iowa and states my rights with respect to my health informa on. I understand Easter Seals Iowa has the right to revise these informa on prac ces and to amend the No ce of Privacy Prac ces. I have been informed that in the event Easter Seals Iowa revises its informa on prac ces, a revised No ce will be posted at each Easter Seals Iowa loca on and that I may obtain a current No ce of Privacy Prac ces at any me from the Easter Seals Iowa State Office or the website at www.eastersealsia.org.
Signature of Client/Guardian/Representa ve Date Signed
If Guardian/Representa ve ‐ State rela onship to client
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EasterSealsIowa
‐HealthHistoryForm‐ClientName:_____________________Birthdate:___________
*pleasecompleteall ieldsandreturnthisform*
In the event of an emergency, I give permission for Easter Seals Iowa to contact the following three individuals: (Please list contacts in the order you would like them to be contacted). In the event of an early discharge please have a plan in place within an hour.
Name: Rela onship: Work Phone: Home Phone: Cell Phone: Name: Rela onship: Work Phone: Home Phone: Cell Phone: Name: Rela onship:
Work Phone: Home Phone: Cell Phone:
Regular Physician: Day me Phone: __
Preferred Hospital: Medicaid ID: __
Insurance Carrier: Policy #:
Please List all allergies and reac ons:_________________________________________________________
_______________________________________________________________________________________
Do you carry an Epi Pen? [ ] Yes [ ] No *If so, please bring your Epi Pen with you to your sessions*
Any recent surgery or illness?
Any Chronic or recurring illness?
Any other informa on?
Does this person have a seizure disorder? [ ] Yes [ ] No Date of last Seizure:____________________
Scheduled, PRN (as needed) and Non‐Prescrip on Medica ons: Dosage:
Name of Person Comple ng Form:
Date: Contact Number:
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MedicationInformation
For Summer Resident Camp:
1. Medicap Pharmacy will be working with us to get all camper medica ons to Camp Sunnyside prior to your session.
2. Please fill out the Medicap Pharmacy Medica on Requirement form, on the next page, in order to ensure your Campers medica ons are prepared for their camp stay.
3. If you should have any ques ons please contact Medicap at the contact informa on provided or feel free to contact our Health Center at 515‐309‐2378.
4. If you are not using Medicap, please send medica ons in packaging as directed below the pictures.
‐We require medica ons sent to us three weeks prior to your camp session.
‐Clearly iden fy your medica on package with the dates of your camp session, first and last name, and date of birth.
‐Due to the significant volume of medica ons administered here at camp, please consider leaving all non‐essen al topical creams, ointments, and other PRNs at home.
All medica on can be sent to:
For Weekend Respite and Supported Day Camp:
‐All medica on can be brought with the camper to check‐in.
‐It must be in a medica on bo le with the correct prescrip on on it. If it is not, the nurse will not be allowed to administer it and your camper may not be allowed to stay at camp.
‐Please only bring the amount needed for each day of camp with one (1) addi onal dose.
Easter Seals Iowa A n: Pa y Gilmore 401 NE 66th Ave
Des Moines, IA 50313
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Prescrip on Medica on Requirements (Must Be Completed)
Dates Camper will be at Camp:________________ to ________________
I Plan to use Medicap Pharmacy to fill medica ons for camp.
I plan to bring the campers medica on to camp.
2804 Beaver Avenue
Des Moines, IA 50310
Phone: 515‐277‐3702
Fax: 515‐277‐3703
Camper Informa on:
Name: DOB:
Address:
City: Zip:
Male Female
Guardian Informa on:
Name:
Phone: Alternate Phone:
MEDICATION STRENGTH DIRECTIONS PRESCRIBING PHYSICIAN
Medica on Informa on (Please complete or send most recent MAR):
All non‐tablet/capsule form medica ons must be brought to camp with the camper. Examples include ointments, creams, liquids,
Current Pharmacy Informa on: Name:
City: Phone:
Medica on packs will be delivered to camp 3 weeks prior to camp star ng.
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Easter Seals Iowa
‐Physical Examina on Form‐Client Name: Birthdate:
Height: Weight:
BP: Pulse:
This form is to be completed by a licensed physician or by a physician's assistant. Other exam forms will not be accepted.
Normal Abnormal
EENT
Heart
Lungs
Resp.
GI
Abdomen
State the most recent date of occurrence:
[ ] Chicken pox
[ ] Measles
[ ] German Measles
[ ] Mumps
[ ] Hepa s carrier
[ ] Rheuma c Fever
Known allergies and reac on:
Epi‐Pen? [ ] Yes [ ] No
I have examined the person herein described and reviewed his/her health history. It is my opinion that he/she
is physically able to engage in any required ac vi es, except as may be noted above, and is free of communica‐
ble or contagious disease.
Signature of examining physician or physician’s assistant Please print name
Fax: Telephone:
Date of Exam: Date Form Completed:
Yes No Please Explain
The applicant is under the care of a physician for
a medical diagnosis/disability.
The applicant can par cipate in the following
adapted ac vi es: Swimming, horseback riding,
zip‐line, rock wall, adventure tree climbing, and
other outdoor ac vi es
The applicant has received a Tetanus Booster
within the last ten years.
Date of most recent Tetanus Booster: ______________________ *please a ach all immuniza on records*
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Easter Seals Iowa Camp Sunnyside
‐2018 Financial Form‐ *This form is required for Resident Camp registra on*
Client Name: ___________________ Birthdate:______________ Do you live in a group home? Yes No
Are you privately paying? [ ] Yes [ ] No *If yes, please fill out this sec on only*
Where would you like us to send the invoice?
Name:_____________________________________ Phone:_______________________
Address:____________________________________ City, State, Zip:_________________
I prefer electronic billing statements Email Address for billing:___________________
Method of Payment:
Check (Make payable to Easter Seals Iowa)
Amount Enclosed: $_________________
Credit Card Visa MasterCard Discover
Amount Authorized: $
Card Number:
Expira on Date: 3 Digit Code:
Name on Card:
Signature:
$50 Deposit Required
Would you like us to charge your card for the remaining
balance the Wednesday before the session? [ ] Yes [ ] No
Reques ng Campship
(not guaranteed—resident camp only)
Clients are eligible to receive one Campship per season,
not to exceed $550. Residents of group homes, nursing
homes, and other facili es are eligible for a maximum
Campship of $250.
Amount Requested: $
$50 deposit required
Please note:
The non‐refundable $50 deposit must be sent with the
applica on. Please do not send the deposit separately. It
will be applied to the first camp session.
Any applica on turned in a er July 1st will require the
camp payment to be made in full before the camper can
be registered.
Are you paying with a waiver? [ ] Yes [ ] No *If yes, please fill out this sec on only*
Managed Care Organiza on (MCO):
[ ] United Healthcare Plan
[ ] Amerigroup Iowa
[ ] HIPP/IME Case Manager Name:
MCO ID Number: Case Manager Phone Number:
Medicaid ID Number: Case Manager Email:
Please contact your case manager before sending in the Applica on and
Registra on forms to ensure the proper funding is in place. A current care
plan, provided by your case manager, is required by registra on. Resident
Camp waiver code T2036 at $1.24 a unit, 484 units total per week.
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Easter Seals Iowa Camp Sunnyside
‐ Summer Resident Camp ‐ Registra on 2018
Private Pay Cost: $600 per week Waiver Rate: $1.24 per unit, 484 units per week
Client Name: Today’s Date:
Medicaid: Date of Birth:
Guardian Name: Guardian Email:_____________________
Guardian Home Number: Guardian Cell Number:
Week 1: June 10‐15 C1 Myth Busters
Week 2: June 17‐22 C2 Under the Sea
Week 3: June 24‐29 C3 Western Week
S2 Extreme Nature 1
Week 4: July 1‐6 C4 Stars and Stripes
Week 5: July 8‐13 C5 Camp Explore/Superheroes
Week 6: July 15‐20 C6 Amazing Race
S2 Extreme Nature 2
Week 7: July 22‐27 C7 Rock and Roll
Week 8: July 29‐Aug 3 C8 Choose Your Own Adventure
Ages 18 and Up
Ages 4—17
Ages 18 and Up
Ages 18 and Up
Ages 4—17
Ages 18 and Up
Ages 18 and Up
Ages 18 and Up
Please choose two alterna ve sessions the camper would like to a end in case your first choices are full.
1. 2.
Client Age:_________
(When a ending camp)
How many weeks are you registering for?________
*Please mark only the session(s) you want to be registered*
Check in is Sunday 2 pm. Check out is Friday 2‐3 pm. Camp registra on closes the Wednesday before the desired camp session. All
applica ons are completed in the order received so please allow two weeks to process. **If camper has never a ended Extreme
Nature in a previous summer you must be approved by the Director of Camp to be registered. If your camper has never a ended
Easter Seals Camp before, an Intake Process will need to occur before you will be registered and may result in a delay in
processing your applica on. If your camper needs 1:1 assistance, please go to www.easterseals.com/ia/camp for more
informa on regarding the registra on process.**
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Important! If you are Privately Paying:
A non‐refundable $50 deposit is required to register a camper. The camper cannot be registered un l we
have received this and we do not reserve or hold spots. The $50 will be applied to the first camp session. Please send the deposit with the applica on to our program and Support Specialist at:
Easter Seals Iowa A n: Camp and Respite 401 NE 66th Ave Des Moines, IA 50313 Full payment is due three weeks before the client a ends his/her camp session. Failure to pay in
advance may result in a loss of registra on for that session. If the remaining balance is sent separately from the deposit and applica on, please send it to out Accoun ng Department at:
Easter Seals Iowa A n: Accoun ng 401 NE 66th Ave Des Moines, IA 50313 The en re amount is required to be paid even if the camper will not a end the en re camp. Any applica on turned in a er July 1st, 2018 will require the camp payment to be made in full before the
camper can be registered. If the camper can no longer a end the registered camp sessions, please contact the Program and Support
Specialist at 515‐309‐2375. Failure to cancel the camp session at least one week before the camp session begins may result in the billing contact iden fied on the Financial Form being charged for the Full camp session.
How to apply for a Campship: Easter Seals Iowa receives funding from a variety of sources, including private dona ons, government agencies, and fee‐for‐service. To make our services accessible to as many people as possible, Easter Seals Iowa also relies on contribu ons. Public contribu ons help cover the difference between actual program costs and for those who are unable to pay for all or part of the service. Each camper is supported by donors who par cipate in the Annual Fund Campaign. The Annual Fund raiser donated funds for these financial gaps. Campships are scholarships that are gi s from the Pony Express Riders of Iowa, the Annual Campaign, founda ons, organiza ons, and individuals. To apply, please fill out the Campship request sec on on the 2018 Financial Informa on page. If applying for Campship, we s ll require the non‐refundable $50 deposit. Deposits are not covered under
the Campship. Please send the deposit with your applica on. If awarded a Campship, you will receive a statement reflec ng that it has been applied to your balance
due. Clients are eligible to receive one Campship per season, not to exceed $550. Residents of group homes,
nursing homes, and other facili es are eligible for a maximum Campship of $250. There are limited Campships and we are reward them on a first come, first serve basis. If you are
interested in receiving one, we strongly encourage you to turn in all required documents for camp as soon as possible.
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Important!
If you are using Waiver Funding:
Please contact your case manager before sending in the applica on. We ask that you discuss with them
how many camps you are interested in, what type (s), and what dates the camps occur on to ensure the
proper funding is in place.
A camper cannot be registered without the correct waiver funding in place and we cannot register out‐
side of what the funding authorizes. We also do not reserve or hold spots.
Please send all funding and billing informa on with the applica on to our Program and Support Specialist:
Easter Seals Iowa A n: Camp and Respite 401 Ne 66th Ave Des Moines, IA 50313 Please also have the case manager send the client’s Individual Care Plan/Consumer Comprehensive Service
Plan (ICP/CCSP) with the applica on. This document is also required for registra on. The en re unit amount per camp is required to be authorized by the waiver, even if the camper will not
a end the en re camp. Below are our waiver rates:
Please Note: The CMH waiver (Children’s Mental Health Waiver) can only be used on our weekend
respite Camps. All other waivers (such as the Intellectual Disabili es Waiver, the Ill and Handicapped
Waiver, and the Brain Injury Waiver) are eligible for both weekend respite camps and our summer resident and supported day camps.
As we transi on to new Managed Care Organiza ons, we may need to make some adjustments to the registra on process. We will communicate those updates as more informa on becomes available.
Supported Day Camp: T2037
$1.11/unit
180 units a week
(220 units per week for extended hours)
Weekend Respite Non CMH: T2036
$3.16/unit
184 units per weekend
or
Resident Camp: T2036
$1.24/unit
484 units per week
Weekend Respite CMH: T2036
$3.34/unit
184 units per weekend
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2018 Resident Camp Themes MythBusters—FactorMyth:ASasquatch(BigFoot)residesatCampSunnyside.HelpusbustthismysteryafteraneveningSasquatchhuntandjoinusforothermythbustingac-tivities!Thisisanadultsession.
UndertheSea—Mermaids,Sharks,andSeaCreaturesOhMY!Thisweekisallaboutfunilledwateractivities!GetreadytospendcountlesshoursatLakeCheerio,searchfortheLochnessmonster,andgetwetandwildaswegoonanadventureunderthesea.Thisisayouthsession.
WesternWeek—Yeehaw!It’sbackagainforanothertimearoundthebarrel!Enjoyaro-deo,horsebackriding,andlotsofCountryWesternMusicduringthishonky-tonkweek.WewillalsoturncampintotheWildWestwithdemonstrationsfromthePonyExpressRidersofIowa.CostumesandWesternwearareencouraged!Thisisanadultsession.
ExtremeNature1&2—Asyoucansee,ExtremeNatureisoffered2timesthissummer,becauseofitsEXTREMEpopularity.Campersgettosleepintents,cookfoodoveranopenire,andhikethroughthewoods.Thiscampissuitableforcamperswhocansleeponthegroundandmaintainaratioof1:7.CampSunnysidereservestherighttoadjustthegroupifwefeelhealthand/orsafetyiscompromised.Thisisanadultsession.
StarsandStripes—CelebrateourgreatNationthisweekwithourFourthofJulycelebra-tion!Thisweekwillbe illedwithmanyfun,patrioticactivities–includingaParade!Comewearingyourred,white,andblue.Thisisanadultsession.
CampExplore/Superheroes—CampExploreisbeingofferedtoallchildreninIowawithvisualimpairments.EasterSealsIowaiscollaboratingwithIowaBrailleSchooltomakethisaspecialsessiondesignedforpersonswithvisualimpairments,butanyoneiswel-cometojoininthefun.Youwillalsogettoexperiencebeingacrime- ightingsuperherointhisfun illedweeksobringyoursuperherocostumes!Thisayouthsession.
AmazingRace—JoininonCampSunnyside'sAmazingRace!Travelaroundtheworldcompletingchallengesandactivitiesduringthisamazingweekadventure.Thisisanadultsession.
RockandRoll—Ifyouliketorockandroll,thiscampisforyou!Withmusicblaringallweeklongonthepatioandaliveperformancebyacoverband,thisweektotallyROCKS!Wealsoencourageourcampers’creativitybymakingmusicandinstrumentsofourown.Thisisanadultsession.
ChooseYourOwnAdventure—Thisweekisallaboutchoosingyourownadventure.Worktogetherwithyourcabintodecideyourfatethroughouttheweek.Areyoureadyfortheadventurethatliesahead?Thisisanadultsession.